emerging trends in california’s - welcome to rn...

Emerging Trends in California’s RN Labor Market

April 19, 2016

Today’s presenters

Joanne Spetz

• Professor, Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco

Judee Berg

• Executive Director, HealthImpact

Teri Hollingsworth

• Vice President, Human Resources Services, Hospital Association of Southern California

Nikki West

• Program Director, HealthImpact

2

Goals for this webinar

Assess how rising demand for health care services is affecting demand for RNs in California

• Learn how Chief Nursing Officers perceive the current RN labor market

• Track the latest hospital vacancy and turnover data

• Understand how recently-graduated nurses are faring

• Address root cause for shortage of nurses in specialty roles

Assess next steps for ensuring an adequate nurse supply

3

The work presented today is supported by…

Funders

• Betty Irene Moore Nursing Initiative

• Kaiser Permanente Northern California Patient Care Services and Kaiser Permanente Nurse Scholar Academy

• California Board of Registered Nursing

Acknowledgements & thanks to…

• Association of California Nurse Leaders

• California Student Nurses Association

• California Hospital Association

• Hospital Council of Northern & Central California

• FutureSense Inc.

• Hospital Association of San Diego & Imperial Counties

• UCSF Staff & Interns: Tim Bates, Lela Chu, Lyubov Loza, Nachu Amah

4

What is going on in our RN labor market?

Reports of nurse surplus 2009-now

• Newspaper stories of new graduates who are unemployed

• Shortage may not have ended in some states

Emerging reports of shortage 2014-now

• Anecdotes about using more contract nurses

• Potential mismatch between needs and skills

What will happen next?

5








6

Survey of Chief Nursing Officers

Fielded by UCSF

Web-based survey with option to return paper survey via fax or email

8 surveys conducted

• Fall 2010, Spring 2011, Fall 2011, Spring 2012, Fall 2012, Fall 2013, Fall 2014, Fall 2015

• Fall 2015 survey: 210 facilities represented

7

Perceptions of employers: Overall labor market

40.1%

18.4%

8.6%

5.5%

4.7%

5.3%

46.9%

49.0%

32.3%

45.2%

43.9%

30.9%

6.8%

13.1%

18.7%

19.8%

6.8%

11.8%

5.6%

12.6%

26.8%

17.1%

23.6%

27.0%

0.6%

6.8%

13.6%

12.4%

20.9%

25.0%

0% 20% 40% 60% 80% 100%

2015

2014

2013

2012

2011

2010

High demand: difficult to fill open positions

Moderate demand: some difficulty filling open positions

Demand is in balance with supply

Demand is less than supply available

Demand is much less than supply available

8

Differences across regions: Overall RN labor market

9

4.2

4.3

4.3

4.4

4.0

3.6

1.0 2.0 3.0 4.0 5.0

Sacramento & North

SF Bay

Central CA

LA

Inland Empire

S. Border

2015

2014

2013

2012

2011

2010

Differences across regions: Experienced RNs

10

4.2

4.2

4.3

4.2

4.6

3.7

1.00 2.00 3.00 4.00 5.00

Sacramento & North

SF Bay

Central CA

LA

Inland Empire

S. Border

2015

2014

2013

Differences across regions: New Grad RNs

11

2.3

1.8

2.3

2.2

2.3

1.5

1.00 2.00 3.00 4.00 5.00

Sacramento & North

SF Bay

Central CA

LA

Inland Empire

S. Border

2015

2014

2013

Rural vs. urban perceptions

4.28 4.18

1

1.5

2

2.5

3

3.5

4

4.5

5

Rural Non-Rural

2010

2011

2012

2013

2014

2015

12

Higher number = more shortage

Change in employment in the past year (2014 - 2015)

62.9%

56.4%

50.0%

30.5%

23.0%

15.9%

7.6%

29.4%

39.1%

35.8%

65.0%

69.9%

70.3%

86.4%

7.7%

3.6%

14.2%

4.6%

7.1%

13.0%

5.1%

0% 20% 40% 60% 80% 100%

New RN graduate

NP

Staff RN

Aide/assistant

Other RN

LVN

CNS

Increased employment No change Decreased employment

13

Hiring requirements and preferences,

52.3%

4.6%

69.5%

21.2%

67.6%

4.8%

80.5%

19.5%

0% 20% 40% 60% 80% 100%

Minimum experience requirement

Baccalaureate degree required

Baccalaureate degree preferred

No specific requirements

2015 2014 2013 2012 2011

14

Plans regarding BSN-educated nurses, 2015

75% plan to increase the share with BSN

(71% in 2014; 66% in 2013)

9% require that hired RNs obtain a BSN within a certain time

(12% in 2014)

39% require a BSN for promotion beyond staff nurse

(55% in 2014)

32% differentiate RN salary by education degree

(32% in 2014)

31% differentiate RN salary by advanced certification

(48% in 2014)

15

Challenges to increasing the share of BSN-educated RNs

Most common barriers to increasing share with BSN:

• Lack of interest among incumbent RNs

• Lack of tuition reimbursement funds

• Lack of funds for financial incentives

• Lack of BSN programs in community

• Low supply of BSN-educated RNs in community

16

Overall hiring expectations for the next year

31.4%23.5%

31.2% 35.1%47.7%

65.4%

50.0% 67.8% 51.6%50.0%

48.1%

33.2%

18.6%8.7%

17.2% 14.9%4.2% 1.5%

0%

25%

50%

75%

100%

Hire fewer than lastyear

No change

Hire more than lastyear

17

Expected RN hiring by care setting for next year (2015 - 2016)

66.7%

50.3%

41.7%

51.5%

62.0%

30.4%

49.7%

58.3%

48.5%

36.8%

2.9%

1.2%

0% 20% 40% 60% 80% 100%

Inpatient care

Ambulatory care

Home health

Long-term care

Casemanagement

Increased hiring No change Decreased hiring

18

Hiring of newly graduated RNs, 2010-2015

84.6% 82.6%77.6% 76.0%

82.9%90.3%

6.7% 9.4%12.6%

7.8%

6.5%

6.3%8.7% 8.0% 9.8%

16.1%10.6%

3.4%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

2010 2011 2012 2013 2014 2015

Do not hire ever

Normally hire,but not this year

Hired this year

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Percent of new hires that were new graduates

34%

6%

26%

32%

15%

31%29%

7%

24%

33%

20%

31%

0%

5%

10%

15%

20%

25%

30%

35%

40%

Full-time Part-time Overall

Fall 2012 Fall 2013 Fall 2014 Fall 2015

20

Hiring of new graduates into non-RN roles

28.6%31.7%

36.6%

0%

10%

20%

30%

40%

50%

2013 2014 2015

Hire into non-RN roles

21

Residency programs for non-employee new graduates, Fall 2015

41 hospitals reported residencies for new graduates not guaranteed to be hired

• Most offered 1-3 times per year

• Most common capacity is 10-15 new grads

• Most common length is 12-16 weeks

• 68% paid program

81% of hospitals said 75-100% of residency completers were hired in last year

• 14% said they hired less than 25%

22

Residency programs for non-employee new graduates, Fall 2015

0% 20% 40% 60% 80% 100%

Medical-surgical

Emergency

Critical care

OR/Peri-op

Obstetrics/newborn

Pediatrics/neonatal

Ambulatory care

Psychiatry

Rehabilitation

23

Hiring expectations for new graduates

21.6% 22.3% 24.1%35.1%

47.3%18.7% 22.3% 14.8%

7.7%

3.5%

59.7% 55.4% 61.1% 57.2%49.2%

0%

25%

50%

75%

100%

2011-2012 2012-2013 2013-2014 2014-2015 2015-2016

Increase hiring Decrease hiring No change

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Reasons for expected increase in new graduate hiring

• Lack of available experienced RNs

• Expected retirement of incumbent RNs

• Expansion of service lines

• Desire to build a pipeline to staff own clinical specialties

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Quarterly hiring of full-time personnel, HASC Survey, Fall 2013 - Fall 2015

3.5%

2.5% 2.5%

3.9%

4.5%

2.3%

2.7%

3.6%

6.4%

2.8%

2.0%

6.3%

0.0%

1.0%

2.0%

3.0%

4.0%

5.0%

6.0%

7.0%

Staff RNs Other RNs LVNs Aides

2013

2014

2015

27

194 responses

RN Vacancies, HASC Survey, 2010 - 2015

3.4%4.0%

3.2%

4.2%4.8%

6.9%

0.0%

1.0%

2.0%

3.0%

4.0%

5.0%

6.0%

7.0%

8.0%

All RNs

Fall 2010

Fall 2011

Fall 2012

Fall 2013

Fall 2014

Fall 2015

28

194 responses

Quarterly turnover of full-time personnel, HASC Survey, Fall 2013 - Fall 2015

2.3%

3.4%

3.1%

2.8%2.6%

2.9%

3.7%

2.5%

3.2%3.3% 3.3% 3.3%

0.0%

0.5%

1.0%

1.5%

2.0%

2.5%

3.0%

3.5%

4.0%

Staff RNs Other RNs LVNs Aides

2013

2014

2015

29

194 responses

Per Diem, Contract, and Agency RN Staff as Percent of Current Staff

0%

2%

4%

6%

8%

10%

12%

14%

16%

2010 2011 2012 2013 2014 2015

Per Diem

Contract

Agency

30

194 responses








31

New RN Graduate Hiring Survey

Statewide survey of new grads conducted in fall of 2015

Collaborators:

• HealthImpact

• California Board of Registered Nursing

• Association of California Nurse Leaders

• California Student Nurses Association

50% random sample of new graduates from Sept 2014-Aug 2015

• 12% response rate in 2015

Funder: Kaiser Permanente Northern California Patient Care Services and Kaiser Permanente Nurse Scholar Academy

32

Findings from the 2015 New RN Graduate Hiring Survey

0%

10%

20%

30%

40%

50%

60%

70%

80%

Fall 2010 Fall 2011 Fall 2012 Fall 2013 Fall 2014 Fall 2015

Percent of new graduates employed in nursing

33

Regional variation in employment

34

75%

63%

73%

80%

70%

86%

76%

67%63%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Employment Rates

LA County

SF Bay

Orange/Inland

N CA

San Diego/Imperial

Central Valley

Sacramento

N Sac Valley

Central Coast

Employment rate varies by education

35

53%55%

59%55%

63%67%

62%

70%

58%

76%78%

50%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

AD BSN ELM*

2012

2013

2014

2015

*Small ELM response rate in the 2015 New RN Graduate Hiring Survey

Employment settings of new graduates

36

Hospital Inpatient

60%Hospital Outpatient

14%

Long Term Care/Rehab

10%

Home Health/Hospice

2%

Community Clinic7%

Behaviorial Health

2%

Corrections0%

Other5%

Why are they not employed?

No experience – 85%

No position available – 37%

BSN preferred or required – 30%

Work experience not applicable – 26%

Weak resume – 12%

37








38

Background

HASC serves the political, economic and educational needs of hospitals in in Los Angeles, Orange, Riverside, San Bernardino, Santa Barbara and Ventura counties

175 member hospitals and health systems

Concerns raised regarding apparent shortage of specialty trained RNs

Engaged HealthImpact to conduct root-cause analysis

In January 2016, HASC convened a workgroup: HR, Nursing and Administrators

39

Background

HASC serves the political, economic and educational needs of hospitals in in Los Angeles, Orange, Riverside, San Bernardino, Santa Barbara and Ventura counties

175 member hospitals and health systems

Concerns raised regarding apparent shortage of specialty trained RNs

Engaged HealthImpact to conduct root-cause analysis

In January 2016, HASC convened a workgroup: HR, Nursing and Administrators

40

Why is it hard to find experienced RNs for specialty positions?

What can be done about it?

41

HealthImpact Engaged to Assist: Southern California Hospitals Seeking a Solution

At request of Hospital Association of Southern California to serve its members

Workgroup of Hospital Leaders: HR, Nursing and Administrators Define Success:

Collaboration across systems instead of competition

Relationship building and strengthening existing connections

Partnering with nursing schools

Sustainable, long-term strategy

Shared belief that newly licensed RNs DO need a formal transition to practice program

42

Process to Address Shortage

Series of meetings to build relationships

Survey instruments and scoring rubric

Article research and evidence to support work

Identify root causes

Validate

Develop recommendations

43

Progress to Date: Specialty Focus Areas

Extrapolated need across region for experienced RNs over 12 mo*:

Peri-operative– 1,072

Critical Care – 2,320

Emergency – 1,392

Labor & Delivery – 864

Neonatal ICU – 688

Care Coordinator and Case Manager –

anticipated to grow

* 17 hospitals in workgroup representing 164 hospitals across HASC total membership

44

Root Causes Identified by Supply and Demand

1.Education insufficient for

specialty role preparation,

especially related to

increasing acuity, complexity

of care, quality and safety

requirements.

2. Loss of experienced level

specialty RN workforce.

3. Resource challenges,

including cost of recruitment

and hiring bonuses.

4. Intensity of specialty work

environment, resulting in

burnout.

45

Which Strategies Make Sense Individually? For the Region?

School-Employer

Transition to

Practice for New

Graduate RNs

School-Employer

Transition in Practice

for Experienced RNs

moving to new roles

Elective

Course /

Externship for

Junior and

Senior RN

students

Dedicated

Education Units

for New Hire RNs

Dedicated

Education Units

for RN students

Academic-Practice

Relationship-

Building

Strategy: Strategy:

Overall ability to

address shortage

Cost to implement

Time to implement

Impact on internal

staff / resources

Benefit across

various specialty

areas

Sustainability

Other

Other

TOTAL

SCORING WORKSHEET

For each category, score 1-4, with 4 being the best or most ideal

46

Emerging Strategies

Junior and Senior Year Elective

Rigorous selection process

Informed by regional demand for specific specialties

Provided by school of nursing w/clinical site shared faculty

Strengthen connection of students to potential employment post-graduation

Pre-licensure: Specialty Immersion

47

Emerging Strategies

Model developed through HealthImpact

Schools/clinical sites partner

Regional approach with option for multiple partners

Schools provide didactic content, course credit, liability coverage

Clinical sites provide preceptors

Possibility of benefit to combining preparation of new grads with experienced RNs moving to new roles

Faculty with right skill set essential

New Graduate and Existing RN Transition Program

48

Emerging Strategies

Regionally based

Draw experienced RN participants from multiple hospitals

Intensive course, held at convenient time for working RNs

Share various aspects of case management/care coordination

Possible blended format, faculty team

Case Management/Care Coordination Course for Experienced RNs

49

Multiple Answers

Stronger Academic/Practice Ties

Joint appointments/shared positions in practice/academia

Appointments to committees, task forces and project focused teams

50

The Future

Collaborative approach

Building a sustainable solution

Expanding capacity

Strengthening academic/ practice partnerships

Focusing on regional needs

Moving Forward

51








52

What is happening now?

There is current and anticipated job growth

• Inpatient care growth in census and higher acuity

• Ambulatory care growth

Shortage of experienced RNs

‒ Operating Room

‒ Labor & Delivery

‒ Emergency Department

‒ Intensive care

Employers are avoiding new graduates

53

California RN graduations per year

6,158

11,291

0

2,000

4,000

6,000

8,000

10,000

12,000

14,000

54

Best supply and demand forecasts for RNs, 2015-2035

55

0

50,000

100,000

150,000

200,000

250,000

300,000

350,000

400,000

450,000

Best Supply Forecast

National 25th percentile FTE RNs/population

OSHPD hours per patient day-based forecast

Low Supply Forecast (low count & employment)

National average FTE RNs/population

Concerns for workforce policy

Will recent graduates who can’t find work leave California permanently?

What education changes are needed to ensure new graduates have the right skills?

Can we foster opportunities to gain on-the-job skills and to pursue additional education?

56

Solutions

Employers: Invest in new graduate hiring

• Less expensive than a shortage

‒ Recruitment costs

‒ Costs of patient care lapses

‒ Costs of rapid wage increases

Specific investments:

• Continuing Education

• Mentoring

• Creative Hiring Practices

• Volunteering

• Transition to Practice Programs

57

Participation in Transition to Practice Programs

Employer Provided Participation – 42.7%

School of Nursing Provided Participation – 2.8

45.5% of New Graduates Participated in a Transition to Practice Program

58

Solutions

Educators: Partner with employers

• Offer electives in the clinical areas of shortage

• Ensure streamlined education progression

Policymakers: Maintain education capacity

• Do not let enrollments drop

• Support scholarship programs such as the HPEF programs

59

Check out the UCSF website!http://rnworkforce.ucsf.edu

57

Interactive data displays

57

Also go to the BRN websiteForms Publications

62

Questions?

Thoughts?

Ideas?

Perspectives?

63

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